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Haves and have-nots prepare as health marketplaces open Oct. 1

  • FILE - In this March 23, 2010 file photo, Marcelas Owens of Seattle, left, Rep. John Dingell, D-Mich., right, and others, look on as President Barack Obama signs the health care bill in the East Room of the White House in Washington. (AP Photo/J. Scott Applewhite, File)

    FILE - In this March 23, 2010 file photo, Marcelas Owens of Seattle, left, Rep. John Dingell, D-Mich., right, and others, look on as President Barack Obama signs the health care bill in the East Room of the White House in Washington. (AP Photo/J. Scott Applewhite, File)

  • FILE - In this Tuesday, March 27, 2012 file photo, Amy Brighton from Medina, Ohio, who opposes health care reform, holds a sign in front of the Supreme Court in Washington during a rally as the court continues arguments on the health care law signed by President Barack Obama. (AP Photo/Charles Dharapak)

    FILE - In this Tuesday, March 27, 2012 file photo, Amy Brighton from Medina, Ohio, who opposes health care reform, holds a sign in front of the Supreme Court in Washington during a rally as the court continues arguments on the health care law signed by President Barack Obama. (AP Photo/Charles Dharapak)

  • FILE - This April 30, 2013 file photo shows the short form for the new federal Affordable Care Act application in Washington. Getting covered through President Barack Obama’s health care law might feel like a combination of doing your taxes and making a big purchase that requires some research. You’ll need accurate income information for your household, plus some understanding of how health insurance works, so you can get the financial assistance you qualify for and pick a health plan that’s right for your needs. (AP Photo/J. David Ake)

    FILE - This April 30, 2013 file photo shows the short form for the new federal Affordable Care Act application in Washington. Getting covered through President Barack Obama’s health care law might feel like a combination of doing your taxes and making a big purchase that requires some research. You’ll need accurate income information for your household, plus some understanding of how health insurance works, so you can get the financial assistance you qualify for and pick a health plan that’s right for your needs. (AP Photo/J. David Ake)

  • Cecilia Fontenot poses at the Texas Organizing Project offices in Houston on Wednesday, Aug. 28, 2013. Fontenot is looking forward to the opening of that state’s federally run insurance market. A part-time accountant in her early 60s, Fontenot is uninsured and trying to stay healthy while coping with diabetes, high blood pressure and high cholesterol. Also, a breast lump was detected about a year ago. Her doctor recommended a digital mammogram, but she has not been able to afford the more involved test. Because of her pre-existing conditions, Fontenot would have a tough time finding affordable individual coverage today. But starting Jan. 1, 2014 insurers will no longer be able to turn away people with health problems or charge them more. (AP Photo/Pat Sullivan)

    Cecilia Fontenot poses at the Texas Organizing Project offices in Houston on Wednesday, Aug. 28, 2013. Fontenot is looking forward to the opening of that state’s federally run insurance market. A part-time accountant in her early 60s, Fontenot is uninsured and trying to stay healthy while coping with diabetes, high blood pressure and high cholesterol. Also, a breast lump was detected about a year ago. Her doctor recommended a digital mammogram, but she has not been able to afford the more involved test. Because of her pre-existing conditions, Fontenot would have a tough time finding affordable individual coverage today. But starting Jan. 1, 2014 insurers will no longer be able to turn away people with health problems or charge them more. (AP Photo/Pat Sullivan)

  • FILE - In this March 23, 2010 file photo, Marcelas Owens of Seattle, left, Rep. John Dingell, D-Mich., right, and others, look on as President Barack Obama signs the health care bill in the East Room of the White House in Washington. (AP Photo/J. Scott Applewhite, File)
  • FILE - In this Tuesday, March 27, 2012 file photo, Amy Brighton from Medina, Ohio, who opposes health care reform, holds a sign in front of the Supreme Court in Washington during a rally as the court continues arguments on the health care law signed by President Barack Obama. (AP Photo/Charles Dharapak)
  • FILE - This April 30, 2013 file photo shows the short form for the new federal Affordable Care Act application in Washington. Getting covered through President Barack Obama’s health care law might feel like a combination of doing your taxes and making a big purchase that requires some research. You’ll need accurate income information for your household, plus some understanding of how health insurance works, so you can get the financial assistance you qualify for and pick a health plan that’s right for your needs. (AP Photo/J. David Ake)
  • Cecilia Fontenot poses at the Texas Organizing Project offices in Houston on Wednesday, Aug. 28, 2013. Fontenot is looking forward to the opening of that state’s federally run insurance market. A part-time accountant in her early 60s, Fontenot is uninsured and trying to stay healthy while coping with diabetes, high blood pressure and high cholesterol. Also, a breast lump was detected about a year ago. Her doctor recommended a digital mammogram, but she has not been able to afford the more involved test. Because of her pre-existing conditions, Fontenot would have a tough time finding affordable individual coverage today. But starting Jan. 1, 2014 insurers will no longer be able to turn away people with health problems or charge them more. (AP Photo/Pat Sullivan)

Having health insurance used to hinge on where you worked and what your medical history said. Soon that won’t matter, with open-access markets for subsidized coverage coming Oct. 1 under President Obama’s overhaul.

But there’s a new wild card, something that didn’t seem so critical when Congress passed the Affordable Care Act back in 2010: where you live.

Entrenched political divisions over Obamacare have driven most Republican-led states to turn their backs on the biggest expansion of the social safety net in a half-century. If you’re uninsured in a state that’s opposed, you may not get much help picking the right private health plan for your budget and your family’s needs.

The differences will be more glaring if you’re poor and your state rejected the law’s Medicaid expansion. Unless leaders reverse course, odds are you’ll remain uninsured. That’s because people below the poverty line do not qualify for subsidies to buy coverage in the markets.

“We are going to have a new environment where consumers may be victims of geography,” said Sam Karp of the California HealthCare Foundation, a nonprofit helping states tackle practical problems of implementation. “If I’m a low-wage earner in California, I may qualify for Medicaid. With the exact same income in Texas, I may not qualify.”

Off the drawing board

The health care law is finally leaving the drawing boards to become a real program with citizens participating. But in many parts of the country, the decisions of Republicans opposed to the law will trump the plans of Democrats who wrote it.

Still, there is a new bottom line. Health insurance marketplaces in every state will provide options for millions of people who don’t have job-based coverage, who can’t afford their own plan or have a health problem that would get them turned down. The feds will run the markets in states that refused to do so.

The coverage won’t be free, even after sliding-scale subsidies keyed to your income.

That’s significant, because starting next year most Americans will also have a legal obligation to get covered or face fines. Some people who now purchase bare-bones individual plans will complain the new ones cost too much. Others, in good health, may resent the government for telling them to purchase insurance they don’t think they need.

Number of uninsured

Nonetheless, the number of uninsured people is expected to drop markedly, bringing the United States closer to other economically advanced countries that guarantee coverage.

The combination of subsidized private insurance through the new markets, plus expanded Medicaid in states accepting it, could reduce the number of uninsured by a quarter or more next year. Current estimates of the uninsured range from about 49 million to more than 50 million.

As Americans get more familiar with the law – and if more states accept the Medicaid expansion – millions more should gain coverage. Many of the remaining uninsured will be people living in the country illegally. They are not entitled to benefits.

Pre-existing conditions

In Texas, Republican Gov. Rick Perry has vowed not to facilitate Obamacare. But Cecilia Fontenot of Houston is looking forward to the opening of that state’s federally run insurance market.

A part-time accountant in her early 60s, Fontenot is uninsured and trying to stay healthy while coping with diabetes, high blood pressure and high cholesterol. She walks twice a day, early in the morning before it gets hot and in the evenings.

Also on her mind is a breast lump detected about a year ago. Her doctor recommended a digital mammogram, but she has not been able to afford the more involved test.

“I try not to worry and just pray on it,” said Fontenot.

Because of her pre-existing conditions, Fontenot would have a tough time finding affordable individual coverage today. But starting Jan. 1, insurers will no longer be able to turn away people with health problems or charge them more.

And the government will provide sliding-scale tax credits that can make premiums more affordable for households earning between 100 and 400 percent of the federal poverty line. That’s $11,490 to $45,960 for an individual, $23,550 to $94,200 for a family of four.

People on the low end of the income scale get more help, as will older people, whose premiums are higher.

With an annual income of about $23,000, Fontenot makes too much to qualify for Medicaid. And her state decided not to expand the program, an option the Supreme Court granted last year as it upheld the rest of Obama’s law.

But she would qualify for subsidized private coverage in the federally run Texas marketplace. She could apply online, through a call center, by mail or in person.

After the government verifies her identity, legal residence and income, Fontenot would be able to take her tax credit and use it to pick an insurance plan. Coverage takes effect Jan. 1.

Picking a plan

She’d have up to four levels of coverage to choose from: bronze, silver, gold and platinum. All cover the same benefits, but platinum has the highest premiums and lowest out-of-pocket costs, while bronze has the lowest premiums and highest out-of-pocket costs.

Fontenot’s share of premiums would be capped at 6.3 percent of her income, or $1,450 a year for a benchmark silver plan. She’d have to squeeze about $120 a month out of her budget, and that doesn’t include her annual deductible and co-payments.

“If I want to stay alive, I’m going to have to budget that in,” said Fontenot.

With insurance, she’d switch to a brand-name diabetes drug that does a better job of controlling her blood sugars – and get that mammogram.

“I am not asking for free stuff,” she added. “I am willing to do my part.”

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